APPLY

Please read the Shared Information Consent Agreement in full and agree below:
By submitting this application I hereby give the Project K9 Services (PK9S) Staff, authority to use the information (including my participation in the PK9S program, verbal testimonies, quotations, photos, emails, text messages or any communication of any kind) shared by me on this day (the application date) or any day thereafter in any corporation-related promotional material including the PK9S websites, brochure, media, press releases, and merchandise.
I acknowledge and agree that PK9S, or others operating on behalf of PK9S may disclose to the public information that I provide to PK9S or its agents, including my Protected Health Information ("PHI"). This PHI may include my name, birth date, address, telephone number, diseases and ailments, medical records and treatment information. This agreement to disclose applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, as amended, and under the rules and regulations thereunder, as well as applicable state law.
PK9S may use and disclose the information provided, including PHI, for the business purposes of PK9S, including but not limited to education, fund raising, advertisement of PK9S, and support of other veterans and individuals who PK9S assists.
With respect to (1) all video footage, photographs recordings, and written materials provided by me to PK9S in connection with the Project K9 Services program; and (2) all print, video, film, recordings and written materials prepared by PK9S or its representatives in connection with the Project K9 Services program in which I appear or am referenced, including, but not limited to, photographs, print materials, commercials, film or video, social media posts, posting on websites or webcasts ((1) and (2) of this paragraph shall collectively be referred to as "Works"), I hereby grant to PK9S and its designees, including assignees and others that PK9S collaborates with, the unrestricted, perpetual, worldwide right to reproduce, copy, modify, create derivative works and otherwise use, display, distribute, exhibit, transmit and broadcast the Works or any part thereof in any media, means or embodiment, now known or hereafter to become known, including my voice, image and identity without further approval or payment to me of any kind. I also hereby waives any right of inspection or approval of my appearance in the Works.

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Service Information

Employment

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K9 Information

Applicant Survey

Shared Information Consent

Supporting Documents